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Background and objectives: After an acute myocardial infarction (AMI) prehospital thrombolysis (PHT) reduces mortality compared with inhospital thrombolysis. In practice, a relatively small proportion of the total population with AMI receives PHT. This study was designed to identify the current barriers to PHT. Methods: A retrospective practice review of 57 consecutive patients treated in or before arrival at a district general hospital emergency department. All patients received thrombolysis for an AMI. Results: The main barriers to delivery of PHT appear to be the inclusion and exclusion criteria laid out in the ambulance service central guidelines. Despite recent widening of the inclusion criteria, 54% of patients eligible for immediate treatment on arrival in hospital either received or were eligible for PHT. Conclusion: To increase the number of patients who are eligible for PHT these guidelines need to be revised further in line with inhospital criteria for thrombolysis. Since the 1970s, a number of landmark treatments have led to a fall in mortality from acute myocardial infarction (AMI). With the introduction of specialised coronary care units (CCU), pharmacological reperfusion therapies, and the use of catheter based interventions, clinical outcomes have markedly improved. However, the key prognostic factor for improved mortality and morbidity is the speed of intervention. It has been consistently proved that early restoration of coronary blood flow in the infarct related artery is needed to preserve functional myocardium. 1In 1996 Boersma et al demonstrated that the duration of coronary occlusion and the extent of collateral circulation are the main determinants of myocardial infarct size.2 Treatment within one hour of symptom onset resulted in a 6.5% absolute reduction in mortality. Figure 1 shows that the benefit of treatment (absolute reduction in mortality) falls with time in a non-linear fashion, clearly demonstrating that very early reperfusion of the occluded coronary artery (within 30 minutes) may lead to full recovery of ischaemic tissue and thus prevent necrosis. Therefore the primary objective in managing patients with AMI is reperfusion as early as possible. 3Both pharmacological and mechanical treatment strategies can be used to achieve reperfusion. The most widely used and established method is pharmacological fibrinolysis. Fibrinolysis, irrespective of the agent used, is usually referred to as thrombolysis. Until 15 years ago, thrombolysis was carried out almost exclusively in a coronary care unit (CCU). However, treatment is most effective when the delay to the delivery of thrombolysis, or call for help to needle time (CTN), is minimised. To improve morbidity and lower mortality, the CTN had to be reduced. In response to this observation, thrombolysis was moved from CCUs to emergency departments (EDs), usually the first point of medical contact for the patient. This was successful in significantly reducing the time from arrival at hospital to the time the thrombolytic drug was administe...

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Introduction: Vaccine hesitancy and delays in vaccine administration time have limited the success of prior influenza vaccination initiatives in the pediatric emergency department (ED). In 2018–2019, season 1, this ED implemented mandatory vaccine screening and offered the vaccine to all eligible patients; however, only 9% of the eligible population received the vaccine. In 2019–2020, season 2, the team sought to improve influenza vaccination rates from 9% to 15% and administer over 2,000 vaccines to eligible ED patients. Methods: Key drivers included: identifying vaccine hesitancy, providing counseling, reducing administration delays, and developing reminders for vaccine administration. We tested interventions using plan-do-study-act cycles. We included discharged ED patients, age 6 months–18 years old, emergency severity index score 2–5, and no prior vaccine this season. Process measures included percent of patients screened, eligible, accepting the vaccine, and leaving before vaccination. Outcome measures were the percent of eligible patients vaccinated and the total number of vaccines administered. Vaccination time was the balancing measure. Results: We included 57,804 children in this study. Comparing season 1 to 2, screening rates (84%) and eligibility rates (58%) were similar. Vaccine acceptance rates improved from 13% to 22%, the proportion of patients leaving before vaccination decreased from 32% to 17%, and vaccination rates improved from 9% to 20%. Total vaccines administered increased from 1,309 to 3,180, and vaccination time was 5 minutes faster in season 2. Conclusions: This ED influenza vaccination process provides a model to overcome vaccine hesitancy and can be adapted and replicated for any vaccine-preventable illness.

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